Submit a Name Change

You will be issued a new Annual Registration Certificate and Wall Display License upon receipt of the following documents:

  1. Dental and Dental Hygienist Name Change Request Form.
  2. Photocopy of legal documentation of the change (marriage license, divorce decree, court order, etc.)
  3. Non-refundable fee.  (See Name Change Request Form for current fee)
  4. Submit a Change of Address Request Form if you have moved within the last 60 days. 

Name Change Request Form